Any down side to 0 wait at ER?

[DwayneEMTP]

http://www.emsresponder.com/article/articl...p;siteSection=1

Michigan System Says ED Patients Will Have Zero Wait

Cooperation from multiple departments successful

Not content with a 30-minute guarantee that it has been offering its ED patients for six years, Michigan's Oakwood Healthcare System has declared that patients will now be seen as soon as they walk though the ED doors. So far, so good, say ED staffers, who concede that the new approach could not have been accomplished by the ED alone.

"A lot of the processes implemented with our 30-minute guarantee were working and continue to work," says Tracy Case, RN, BSN, clinical nurse manager of the 62-bed ED at Oakwood Hospital and Medical Center, Dearborn (one of the system's five EDs). Case was involved in the original implementation of the 30-minute guarantee. "A lot of what initially happened was structured in the ED, but we all had to focus on this together to make [the zero wait time] work," Case says. The ED is very much affected by the rest of the hospital "because we need throughput to get patients admitted up to the floor," she says.

The impetus for the new policy came directly from the ED's patients, explains Lori Stallings, RN, BSN, director of emergency services. "As a system, we have spoken to our customers since the implementation of the 30-minute guarantee," Stallings says. They have had multiple surveys and telephone conferences conducted by the marketing department, she says. "More than a guarantee [of a short wait], they were looking to get to a physician and have their care started immediately," Stallings says.

This reduction in wait time required a "Herculean" effort on the part of a multidisciplined process improvement team, formed in 2005. That team consisted of about 800 people, including a central corporate division and smaller teams involving every manager and medical director. Participating departments included everything from transportation to administration. For example, the radiology department went to a 10-minute turnaround on transcriptions (printing, reading exams.) "That's down from what could have been up to an hour," notes Stallings. "The labs also improved their robotic system to help decrease patient length of stay."

More monitored beds were added to the hospital; thus, in the ED there usually is a bed ready for patients in less than 30 minutes.

To accommodate patients who needed but could not get a monitored bed, the observation area was expanded and a transitional unit was created on the fifth floor that was directed and managed by Stallings. "This allows those patients to move out of the ED," she explains. "They are still in a hospital bed, cared for by an attending physician, but they are not in the ED on a stretcher."

In the past, a cath lab patient who may have been able to be discharged in the morning might have still occupied a telemetry bed in the monitored unit. Now, that bed can be freed for a patient who needs monitoring in the unit.

How it works

The new system works like this: When walk-in patients arrive in the ED, the first person they see and are greeted by is an RN, who is always stationed within five feet of the door. Their complaint is taken, and they are registered immediately by someone from the registration staff. "Then they are taken directly to a triage room where, depending on the complaint, care is started immediately," says Stallings.

There is a set of specific guidelines created by the performance improvement teams and signed off on by the medical director that cover care the nurses can provide if the patient cannot see a physician right away, says Stallings. "These include extremity X-rays, urine tests, lab work — different things that may facilitate throughput," she explains. "They are utilized frequently, to ensure the patient is actually getting care started even if they are not getting to a physician immediately." ( See example of the guidelines for chest pain)

All of the ED staff has been trained on the new policy and procedures. "We don't start anything here unless 85% of the staff has been inserviced," says Stallings.

Since the new policy has been implemented, there has been an increase in patient volume and in admissions, with the inpatient side of the hospital responding effectively in getting the patients in-house, Stalling reports. "Press-Ganey [patient satisfaction] scores have risen systemwide, patients are much happier, and our exit surveys have been very positive," she says, adding that one of the smaller EDs in the system said they recently received an 85% Press Ganey score on "likelihood to recommend." "Ours here are not quite that high, but they have almost doubled from what they were just a couple of months ago," she adds.

Stallings insists that EDs of any size could do what Oakwood has done. "One of our EDs has nine beds, and we have 62," she points out. "What you need is the support of the administration and the undivided support of the inpatient side as well."

[VentMedic]

Build it and they will come.

Even with the 30 minute wait, our ER was swamped with people both with and without insurance that did not want to wait in a doctor's office. Instant gratification.

People also thought a doctor would be there to greet them upon their entrance. The doctor usually didn't appear until much later when the labs/xrays results started to come back. Then our business office took a flood of complaints...like the pizza; 30 minutes or its free. Our hospital did offer to make the ER registration fee free...about $100- $200 dollars. The other $2000 is all yours.

Now we don't advertise. But, we do have a "fast track" route for readily identifible in and out things;...the triage nurse can get labs and xrays started if needed.

STAT protocols should already be in place in many ERs for the more serious issues to get things rolling.

[Ridryder 911]

This is an old trick PR and managers want to try... I did. The trick is you will be seen in 30 minutes or less... yes, but by whom ? Yes, it is true a medical person will see you ... that is a triage nurse. Now, if you read the fine print as described ' you are met by a nurse "... Now, we basically abandoned the triage nurse and do "bedside registration and triage". With portable computers and we are now paperless patients are brought straight back after a c/c is found out.

This has decreased the wait time, but complaints remain the same because peoples expectations are those of a drive through.

R/r 911

[Dustdevil]

This is an old trick PR and managers want to try... I did. The trick is you will be seen in 30 minutes or less... yes, but by whom ?

Yep. And then after you are seen by "whom," where do you go? Beds are all already full thanks to the onslaught of customers. So yes, you are seen right away. Then you go sit in the waiting room for the next two hours until a doctor finally gets the chance to look at the urine specimen you left when you first got there.

Smoke and mirrors. The hospital got out of it exactly what they wanted: free press.

[ReD]

we do the same thing in the ER i work in. We call the room where the patients go to after triage, the Rapid Assessment & Triage room.....R.A.T. We had alot of complaints about patients being taken to a RAT room, and being called a RAT patient. so they just kept the name and said we'd get written up if we said RAT on the intercom.

it DID make a big difference in that we get treatment started on everyone, and the docs like it because they have test results when they see the patients(because they stay ion the RAT room for 8-10 hours sometimes).

they also instituted a "Medical Screening Exam" a couple of months ago, where a NP from one of our clinics basically re-triages the patients and decides weather they go to our fast track area, RAT room, directly to a bed, or should be discharged and sent to our family health clinic. only thing is, these NPs don't have ER experience, and are not well versed in our policies and procedures, and end up sending patients to fast track that should go directly to a bed, and vice versa. the original triage nurses usually has to go back and change the disposition of the patient...........oh, and the medical screening examiner only works weekdays from 9-5 and takes an hour lunch. so when they're not there, things go like they used to before we started all of this.....whats the point?

oh i love the politics of workin in an ER........

[AZCEP]

Here's a thought, if a bit off topic.

How about putting a triage provider/PA/NP in a kiosk in the parking lot? Patient drives up, the "doc in a box" does an assessment and tells them what the best way for them to proceed would be. Part parking attendant/part triage desk/part referral service.

Oh, and put a big bottle of Tylenol in the box with them. For all of the untreated fevers you know.

[Just Plain Ruff]

I am afraid that this is setting a precedent that we are not wanting to go towards. If you say "hey we'll see you in 30mins or less" or better yet "walk in the door and you'll see a provider right away" and you SET up hospitals that cannot afford to do this.

95% of the time the patient will and I repeat WILL be seen by a nurse and that is misleading since patients seem to think that they will be seen by a doctor in 0 minutes.

Again we are catering to the people who don't want to wait for their doctors office appointment and come to the ER and dang it I've been guilty of it but It was justified. My son had a dr appointment at 2pm his fever went from 100 to 104.5 in about 30 minutes I bypassed the docs office.

But for our society we are already pampered and coddled when it comes to healthcare. We want it quick and if we cannot get it RIGHT NOW we go to the ER and get mad when we have to wait there. By golly it's an emergency room and my emergency is more important than yours.

What's next, parking lot docs or better yet, call the ER and they diagnose and treat over the phone and deliver the medications to your door

I have never agreed with a 0 minute wait time or 30 minute wait because it sets up unreal expectations of the public that they will be seen by a doctor.

You gotta love hospital marketing departments.

oh and one other thing

Medicine will NEVER EVER be paperless - I'm in that line of work, making hospitals as paperless as possible and there will never be any such animal as a paperless hospital

[chbare]

I have to agree with many of the other people on this topic. We will never have a system that satisfies people. The expectations of the general public are in most cases outrageous and out of touch with reality. Many of this nations pampered citizens turn into primary sociopaths that care only about them selves when they get a cough. They bypass the family provider with the expectation of cart la blanch service at the local ER. Then, they become volent and aggressive when a doc fails to look down their throat within 5 minutes of presentation because the doc is tubing a four year old who was ejected from the bed of a pick up at 80 MPH. I worked for a hospital that advertised in a similar way. Yes, people were seen and triaged within a few minutes, then most were booted back out into the waiting room. We cannot expect a zero wait time, especially with people using the ER as their private clinic. In addition, you have overcrowded ER's with backed up admits and intubated patients taking up space in the hallway. This is in addition to stalled out medical/surgical units and ICU's that cannot accept admits because they are full. Unfortunately, I think many people would not even respond to a massive education campaign regarding health care, I could not even get parents to do something as simple as rotating tylenol and motrin for fever. (even after seeing and attempting to educate the family multiple times) Loose loose situation for all parties involved.

Take care,

chbare.

[ReD]

oh and one other thing

Medicine will NEVER EVER be paperless - I'm in that line of work, making hospitals as paperless as possible and there will never be any such animal as a paperless hospital

SO TRUE!!! we have all computer charting at the hospital i work at. everytime the patient is moved(weather from one part of the ER to another, or to an admit area or discharged) a copy of the notes is printed. its the same notes, just gets longer and longer with each print. no one throws the old version away. and lab & radiology reports for EVERY patient print on EVERY printer in patient care areas in the ER. i SWEAR that ill throw away a whole ream of paper when i clerk, 2 on a busy day.

also, all of the discharge papers are printed in duplicate, one copy with the pt, one with us....theyre computer generated and can be easily re-printed for that pt with the click of a button(sop when pts loose them we can re-issue them) so that totally defeats the purpose of us keeping a printed copy...........stupid stupid stupid.

[firespec35]

I'm doing my paramedic clinicals in one of the ER's highlighted in the article. It doesnt work. They are at about 20% on getting EKG's done in 10 minutes. They really don't have the staffing to do it. There are times us students have to operate as techs to help them out. I don't mind I really love the staff there and I am happy to help them out but I hear them talking and It's not good.